Provider Demographics
NPI:1699585851
Name:CHAN, SERGIO L
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:L
Last Name:CHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12405 SW 56TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-5518
Mailing Address - Country:US
Mailing Address - Phone:786-468-9316
Mailing Address - Fax:
Practice Address - Street 1:12405 SW 56TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-5518
Practice Address - Country:US
Practice Address - Phone:786-468-9316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator